Images in Clinical Medicine
Paradoxical Embolus
N Engl J Med 2001; 345:803September 13, 2001
- Article
Figure 1 An 18-year-old woman who had flown from England to the United States presented to the emergency room with shortness of breath and numbness of the right arm. She had been taking oral contraceptives until two months before presentation. A computed tomographic (CT) pulmonary angiogram reformatted in the coronal orientation showed numerous filling defects within the main pulmonary arteries (arrowheads in Panel A) consistent with the presence of pulmonary emboli, as well as a filling defect in the right subclavian artery at the branch of the vertebral artery (long arrow) consistent with the presence of a systemic arterial embolus and accounting for the symptoms in her right arm. The finding of an opacity at the left costophrenic angle (short arrow in Panel A) was suggestive of pulmonary infarction, classically described as “Hampton's hump” when seen on chest radiography. A patent foramen ovale (arrow in Panel B) was identified, from which dense contrast material was leaking from the right atrium (RA) to the left atrium (LA); this finding was confirmed by transesophageal echocardiography. The right atrium was enlarged as a result of elevated pulmonary pressure, and there were additional emboli in lower-lobe branches of the pulmonary arteries (arrowheads in Panel B). The emboli were most likely caused by deep venous thrombosis from the patient's legs. A CT image of the distal thighs showed a residual clot (arrow in Panel C) in the left distal superficial femoral vein. The patient's symptoms resolved after she underwent catheter-directed thrombolysis of the subclavian-artery embolus and received systemic thrombolytic treatment for the pulmonary embolism. The patent foramen ovale was closed. There was no obvious laboratory evidence of hypercoagulability.
Frandics P. Chan, M.D., Ph.D.
Timothy R. Jones, M.D.
Stanford University Medical Center, Stanford, CA 94305-5105- Citing Articles (4)
Citing Articles
1
Narendrakumar Alappan, James M. Tauras, Cynthia C. Taub. (2010) Trouble in Transit. The American Journal of Medicine 123:8, 709-710
CrossRef2
Patrick O. Myers, Amir-Ali Fassa, Aristotelis Panos, Marc Licker, Henri Bounameaux, Herve O. Zender, Afksendiyos Kalangos. (2008) Life-Threatening Pulmonary Embolism Associated with a Thrombus Straddling a Patent Foramen Ovale: Report of a Case. Journal of Cardiac Surgery 23:4, 376-378
CrossRef3
K.S. DESHPANDE, C. HATEM, M. KARWA, H. ULRICH, T.K. ALDRICH, V. KVETAN. (2002) The use of inferior vena cava filter as a treatment modality for massive pulmonary embolism. A case series and review of pathophysiology. Respiratory Medicine 96:12, 984-989
CrossRef4
Paul L. F. Giangrande. (2002) Air travel and thrombosis. British Journal of Haematology 117:3, 509-512
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